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Histopathological Patterns of Nephrocalcinosis: a Phosphate Type Can Be Distinguished from a Calcium Type

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Histopathological Patterns of Nephrocalcinosis: a Phosphate Type Can Be Distinguished from a Calcium Type Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2012 Histopathological patterns of nephrocalcinosis: a phosphate type can be distinguished from a calcium type Wiech, T ; Hopfer, H ; Gaspert, A ; Banyai-Falger, S ; Hausberg, M ; Schröder, J ; Werner, M ; Mihatsch, M J Abstract: BACKGROUND: The etiology of nephrocalcinosis is variable. In this study, we wanted to elucidate whether the histopathological appearance of calcium phosphate deposits provides information about possible etiology. METHODS: Autopsy cases from the years 1988 to 2007 and native kidney biopsies from a 50-year period (1959-2008) with nephrocalcinosis were identified. The biopsy cases were re-evaluated by light microscopy. The autopsy cases were analysed according to the underlying disease. The biopsy cases were grouped with respect to the likely etiology of nephrocalcinosis. Total number, den- sity, localization, size and pattern of all calcification foci were documented and correlated with clinical and laboratory data. RESULTS: About 223 of 12 960 autopsy cases (1.7%) had nephrocalcinosis, 111 of which (49.8%) suffered from advanced malignant tumours. Nephrocalcinosis was the main diagnosis in 48 of 12 480 native kidney biopsies (0.4%). Clinicopathological correlation revealed a specific pat- tern of calcification associated with hyperphosphataemia and/or hyperphosphaturia: these cases showed predominant globular or shell-like calcifications (phosphate type). In contrast, the biopsies of thehy- percalcaemic/hypercalciuric group had a different predominant pattern with clumpy or finely granular calcifications (calcium type). CONCLUSIONS: Our results indicate that hyperphosphaturia-associated cases of nephrocalcinosis can be distinguished from hypercalciuria-associated cases histopathologically. DOI: https://doi.org/10.1093/ndt/gfr414 Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-50420 Journal Article Published Version Originally published at: Wiech, T; Hopfer, H; Gaspert, A; Banyai-Falger, S; Hausberg, M; Schröder, J; Werner, M; Mihatsch, M J (2012). Histopathological patterns of nephrocalcinosis: a phosphate type can be distinguished from a calcium type. Nephrology, Dialysis, Transplantation, 27(3):1122-1131. DOI: https://doi.org/10.1093/ndt/gfr414 NDT Advance Access published July 29, 2011 Nephrol Dial Transplant (2011) 0: 1–10 doi: 10.1093/ndt/gfr414 Original Article Histopathological patterns of nephrocalcinosis: a phosphate type can be distinguished from a calcium type Thorsten Wiech1,2, Helmut Hopfer3, Ariana Gaspert4, Susanne Banyai-Falger5, Martin Hausberg6, Josef Schro¨der7, Martin Werner2 and Michael J. Mihatsch3 1Centre of Chronic Immunodeficiency, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany, 2Institute of Pathology, University Hospital Freiburg, Freiburg, Germany, 3Institute for Pathology, University Hospital Basel, Basel, Switzerland, 4 5 6 Institute of Surgical Pathology, University Hospital Zurich, Zurich, Switzerland, Klinik St Anna, Luzern, Switzerland, Sta¨dtisches Downloaded from Klinikum Karlsruhe, Karlsruhe, Germany and 7Institute of Pathology, University Hospital Regensburg, Regensburg, Germany Correspondence and offprint requests to: Thorsten Wiech; E-mail: [email protected] Abstract associated with nephrolithiasis. Pathologists distinguish be- Background. The etiology of nephrocalcinosis is variable. tween oxalosis and nephrocalcinosis, the latter again cover- http://ndt.oxfordjournals.org/ In this study, we wanted to elucidate whether the histopa- ing different compositions but excluding calcium oxalate. thological appearance of calcium phosphate deposits Traditionally, pathologists used the term ‘calcium nephro- provides information about possible etiology. sis’ for dystrophic calcification i.e. calcification of necrosis Methods. Autopsy cases from the years 1988 to 2007 and and the term ‘nephrocalcinosis’ for metastatic calcification native kidney biopsies from a 50-year period (1959–2008) [1]. In our study, we defined nephrocalcinosis as metastatic with nephrocalcinosis were identified. The biopsy cases renal calcifications (excluding oxalosis) by histopatholog- were re-evaluated by light microscopy. The autopsy cases ical detection of calcium deposits without associated tissue were analysed according to the underlying disease. The bi- necrosis. at Universitaetsspital on October 27, 2011 opsy cases were grouped with respect to the likely etiology Nephrocalcinosis can be classified according to the local- of nephrocalcinosis. Total number, density, localization, ization of the deposits: calcium can precipitate predomi- size and pattern of all calcification foci were documented nantly in the medulla, as for example in the medullary and correlated with clinical and laboratory data. sponge kidney. Calcifications mainly located in the renal Results. About 223 of 12 960 autopsy cases (1.7%) had cortex are found, for example, in cortical necrosis. In con- nephrocalcinosis, 111 of which (49.8%) suffered from ad- trast to ultrasonography or computed tomography, light mi- vanced malignant tumours. Nephrocalcinosis was the main croscopy can further distinguish whether calcifications are diagnosis in 48 of 12 480 native kidney biopsies (0.4%). localized in the tubular lumens, tubular epithelium, tubular Clinicopathological correlation revealed a specific pattern basement membrane or in interstitial space [2]. On the other of calcification associated with hyperphosphataemia and/or hand, nephrocalcinosis can be classified according to the hyperphosphaturia: these cases showed predominant glob- chemical composition, which is likely associated with the ular or shell-like calcifications (phosphate type). In con- etiology of renal calcification. Typically, calcium precipi- trast, the biopsies of the hypercalcaemic/hypercalciuric tates with anions in the kidney forming calcium oxalate or group had a different predominant pattern with clumpy or finely granular calcifications (calcium type). calcium phosphate (as hydroxyl apatite) deposits. Conclusions. Our results indicate that hyperphosphaturia- Renal calcium deposits occur (i) in disorders associated associated cases of nephrocalcinosis can be distinguished with impaired homeostasis and an increased renal excretion from hypercalciuria-associated cases histopathologically. of calcium or phosphate or (ii) by an altered solubility, e.g. due to a locally altered pH value in the course of renal Keywords: colonoscopy; histopathology; hypercalciuria; tubular acidosis, hypocitraturia or tissue necrosis. Apart hyperphosphaturia; nephrocalcinosis from that, factors facilitating crystal adhesion to the tubular epithelium seem to be a prerequisite for nephrocalcinosis [3–5]. Hypercalciuria can occur with hypercalcaemia (see Introduction Table 1, e.g. in primary hyperparathyroidism, elevated vi- tamin D3, sarcoidosis) or with normal serum calcium levels Nephrocalcinosis is a clinical term defined as the renal (idiopathic hypercalciuria). In analogy, hyperphosphaturia deposition of calcium. This definition includes deposits can be associated with hyperphosphataemia or with normal of different chemical composition, such as calcium oxalate or low serum phosphate levels due to impaired reabsorption or calcium phosphate, and can, but does not have to be in the tubules. Ó The Author 2011. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: [email protected] 2 T. Wiech et al. Table 1. Clinicopathological data of 48 biopsy cases with nephrocalcinosisa Gender Age Calcification Calcification Clumpy Granular Globular Shell- Onion (M/F) (years) Disease/condition type (Ca/P) foci (number) (%) (%) (%) like (%) skin (%) Hypercalciuria M 52 Lung cancer Ca 10 10.0 60.0 10.0 20.0 0.0 M 3 Lymphoblastic Ca 5 40.0 60.0 0.0 0.0 0.0 leukemia M 25 Sarcoidosis Ca 15 13.3 66.7 20.0 0.0 0.0 M 51 Sarcoidosis Ca 19 15.8 36.8 31.6 10.5 5.3 M 49 Sarcoidosis Ca 5 40.0 60.0 0.0 0.0 0.0 F 65 Hyperparathyreoidism Ca 6 16.7 83.3 0.0 0.0 0.0 F 34 Hyperparathyreoidism Ca 12 25.0 66.7 8.3 0.0 0.0 M 43 Paracellin 1 mutation Ca 5 60.0 40.0 0.0 0.0 0.0 M 13 Dent’s disease Ca 4 0.0 100.0 0.0 0.0 0.0 Hyperphosphaturia F 62 Phosphate purgatives P 11 0.0 0.0 9.1 72.7 18.2 M 75 Phosphate purgatives P 27 3.7 14.8 29.6 40.7 11.1 F 67 Phosphate purgatives P 3 0.0 0.0 66.7 33.3 0.0 F 69 Phosphate purgatives P 29 0.0 0.0 37.9 62.1 0.0 F 78 Phosphate purgatives P 18 11.1 11.1 27.8 50.0 0.0 F 49 Phosphate diabetes P 9 22.2 11.1 44.4 22.2 0.0 Downloaded from M 10 Nephrotic syndrome Ca/P 6 0.0 50.0 50.0 0.0 0.0 F 2 Nephrotic syndrome P 23 0.0 26.1 34.8 39.1 0.0 M 1 Nephrotic syndrome P 8 12.5 25.0 12.5 50.0 0.0 Unknown cause F 69 Unknown Ca 13 0.0 53.8 7.7 23.1 15.4 M 23 Unknown P 9 33.3 0.0 22.2 44.4 0.0 M 46 Unknown Ca 1 100.0 0.0 0.0 0.0 0.0 F 42 Unknown P 3 33.3 0.0 66.7 0.0 0.0 http://ndt.oxfordjournals.org/ M Unknown Ca 149 73.8 26.2 0.0 0.0 0.0 F 2 Unknown Ca 36 61.1 33.3 0.0 2.8 2.8 M 18 Unknown Ca 5 80.0 20.0 0.0 0.0 0.0 M 37 Unknown P 15 13.3 6.7 13.3 66.7 0.0 F 44 Unknown P 11 18.2 27.3 18.2 36.4 0.0 F 69 Unknown P 29 6.9 0.0 17.2 75.9 0.0 F 39 Unknown P 9 11.1 22.2 0.0 66.7 0.0 M 29 Unknown Ca 22 63.6 27.3 4.5 0.0 4.5 F 50 Unknown Ca 3 33.3 33.3 33.3 0.0 0.0 F 30 Unknown P 9 0.0 44.4 22.2 33.3 0.0 at Universitaetsspital on October 27, 2011 F 51 Unknown Ca/P 4 50.0 0.0 0.0 50.0 0.0 F 61 Unknown P 21 0.0 23.8
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